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Page 1 of 31 © 2018 Bill & Melinda Gates Foundation Grant Proposal Narrative 3/29/18
Grant Proposal Narrative This is a proposal shaping document and not a commitment by the foundation to fund the work.
General Information
Proposal Title iDSIplus: Strengthening and scaling countries’ institutional capacities to make better decisions for health
Investment Duration (Months)
60
Proposal Details
1. Executive Summary
Provide a brief summary of the investment.
The international Decision Support Initiative (iDSI) will continue to grow and consolidate a global platform for realising value for
money in healthcare spending. We shall work together with low- and middle-income country (LMIC) governments and global
development funders to create lasting, country-owned institutional capacity for evidence-informed priority-setting and investing in
the most cost-effective and equitable priorities for better population health.
iDSIplus will build on the track record and legacy of the global iDSI network, whose core partners1 comprising government
agencies, thinktanks and academic institutions have a decade of experience in institutionalising and capacity-building for evidence-
informed priority-setting in LMIC health systems. Thanks to iDSI support, 7 LMICs have made tangible institutional progress towards
the embedding of health technology assessment (HTA) into national health priority-setting, health benefits package (HBP) design
and listing, and commodity procurement for universal health coverage (UHC), including: South Africa, Ghana, India, China,
Philippines, Indonesia and Vietnam. iDSI has also contributed to early progress in influencing HBP design through legislation and
foundational convening of national committees in Kenya, Tanzania, Zambia, and Bhutan. Our influence, impact and trust among
LMIC and development partners is evident from the numerous letters we have received (see Appendix) in support of iDSI’s funding
renewal.
Our vision for iDSIplus is a flourishing network and a global resource for LMIC governments, payers, and development partners to
enhance value for money in global health – leading to more cost-effective, equitable and sustainable resource allocation and
guidance that will translate into higher quality healthcare coverage, reduced financial impoverishment for households, and ultimately
better health and more lives saved.
In the next 5 years, iDSIplus will work with policymaker counterparts to embed evidence and good governance into domestic
investment decisions at national and subnational levels in our flagship countries Kenya, South Africa, Ghana, India, China –
which have transitioned or are due to transition from Gavi and Global Fund for AIDS, TB and Malaria (GFATM) assistance – and
beyond through our regional hub strategy for scaling up and diffusing on of impact in Sub-Saharan Africa (SSA). iDSIplus will help
countries to develop sustainable mechanisms for effective, evidence-informed priority-setting, and this will involve mobilising a
wide range of capacities among country stakeholders2 – not only the technical capacity to “do” research in economic evaluations.
Our practical support may include, for example:
• sharing of real-life examples by our Thai and Chinese government partners, of using HTA to enhance health system
efficiency and equity towards sustainable UHC, with senior LMIC client policymakers on a peer-to-peer level;
• giving tailored guidance on how to operationalise transparent and accountable HTA institutional structures and navigate
political economy challenges within the country’s context;
• training and coaching to local technical and research teams to generate robust HTA evidence which can then inform
policy, and in doing so strengthening their capacity to generate as well as translate knowledge.
We shall also enhance and contextualise our knowledge products and global knowledge platforms on health economics and other
disciplines related to evidence-informed priority-setting, particularly with the SSA audience in mind - for instance using innovative
models such as massive open online courses (MOOCs) to deliver our What’s In, What’s Out guide to HBP design. This will help
to diffuse knowledge and build capacity at scale, across and beyond SSA.
iDSIplus will help countries achieve:
• More efficient and equitable allocation of government and spending on health, projected to reach $89bn by 2020 in SSA
alone
1 Currently: Center for Global Development (CGD); Global Health and Development Group, Imperial College London (GHD; the team formerly known as NICE International); National Health Foundation (NHF) and Health Interventions and Technology Assessment Program (HITAP), Thailand; Priority Cost Effective Lessons for System Strengthening South Africa (PRICELESS SA), Wits University School of Public Health; and China National Development and Research Center (CNHDRC) 2 Li R, Ruiz F, Culyer AJ et al. Evidence-informed capacity building for setting health priorities in low- and middle-income countries: A framework and recommendations for further research [version 1; referees: 2 approved]. F1000Research 2017, 6:231 (doi: 10.12688/f1000research.10966.1)
https://www.dropbox.com/sh/gqy6aup7t6xwwvc/AAA2oDv8SnCuQmyqtjBdzt7Ra?dl=0https://www.hfgproject.org/wp-content/uploads/2013/09/Universal-Coverage-of-Essential-Health-Services-in-Sub-Saharan-Africa-Pr.pdf
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Page 2 of 31 Grant Proposal Narrative to the Gates Foundation
• More and more equitable access to cost-effective, good quality care under UHC for the total population in the above
geographies projected to reach 4.6bn by 2030
• Timely adoption of good value technology and innovation in pharmaceuticals markets that will be worth over US$257bn
across Africa, China, and India by 20223
At a time when aid initiatives in emerging markets are being scaled down, sharing and diffusing iDSI’s global expertise is a low cost
means of supporting the development of Southern centres of excellence so that countries can focus their transition on smart spending.
Describe the charitable purpose of this work by completing the statement “This grant will be used [to …].” Please limit to one
sentence, begin with “to” and do not include a period at the end. Example: “This grant will be used [to fund new schools and assist
other organizations in the design of new schools]”
This grant will be used to reinforce a global platform for realising value for money in healthcare spending, working together with
LMIC national governments and global development funders to create lasting, country-owned institutional capacity for evidence-
informed priority-setting and investing in the most cost-effective and equitable priorities for better population health
2. Problem Statement
Describe the problem, why it is a problem, and who is impacted by the problem. What specific elements of the problem is
this investment trying to address?
The most cost-effective health interventions produce as much as 15,000
times the benefit as the least cost-effective. In sub-Saharan Africa, less than
US$4 out of every US$100 in public budget monies go to the health
maximizing intervention or technology. Up to US$2.8tn spent annually on
healthcare is said to be wasted.4 This means that hundreds, thousands, and
even millions of deaths are a direct result of our inability to allocate
according to maximum health gain. Although public budgets are set to grow,
if we fail to reverse inertial and wasteful resource allocation by governments,
we will squander most of the value of the additional resources available, or
end up funding highly cost-effective interventions in an ad hoc and funder-
dependent way.5
Decisions that result in the cost-effective allocation of scarce public
monies for health will ultimately determine whether LMIC governments can
rapidly improve health. In the absence of robust processes to assess the
comparative costs and benefits of health interventions for public funding,
such decisions are prone to be driven by inertia and lobbying rather than
science, economics, ethics, and the public interest. Many more lives could
be saved, health equity enhanced, and potential financial impoverishment
for the poor averted, by reallocating public and funder monies toward the
most cost-effective and equity-enhancing health interventions and
technologies.
Yet too many LMIC health systems lack the tools and institutional
mechanisms to prioritise the interventions and products that generate the
most health for the money. This will involve mobilising among country
stakeholders a wide range of capacities6, which include: the technical
capacity and methods to generate and weigh up economic and other
relevant evidence, articulate opportunity costs, and make informed
choices; the policy mechanisms to ensure that cost-effective interventions
are routinely assessed and funded; and the robust, accountable
institutions and transparent governance processes to manage conflicting
interests and to directly, routinely influence budgets, resource allocation, and purchasing in healthcare.
iDSI will directly address the weakness in priority-setting methods, capacity and processes, and respond to demand for knowledge
diffusion and translation, bridging the disconnect between evidence and the policy decisions that drive allocation of public and
external funder monies across LMICs.
Sub-Saharan Africa: a changing health and development landscape
Challenges stemming from inefficient resource allocation are particularly stark in Sub-Saharan Africa (SSA), with growing pressures
on public health systems as the population is projected to grow from 1.03bn in 2016 to 1.4bn by 2030. Economic and
sociodemographic changes (including a growing urban poor and expanding middle-class) are contributing to increasing non-
3 Mckinsey and Company: “Africa – an opportunity for Pharma and Patients UNIDO 2018” 4 WHO World Health Report 2010 5 As in Good Ventures’ funding to buy amoxicillin in Tanzania 6 Li R, Ruiz F, Culyer AJ et al. Evidence-informed capacity building for setting health priorities in low- and middle-income countries: A framework and recommendations for further research [version 1; referees: 2 approved]. F1000Research 2017, 6:231 (doi: 10.12688/f1000research.10966.1)
Decisions made without following sound principles of explicit
priority-setting – even well-intentioned guidance offered by
global development partners influencing those decisions – can
have real negative consequences for health systems:
● The World Health Organization (WHO), in its 2013 HIV
guidelines, gave a ‘strong’ recommendation for the
widespread adoption of viral load monitoring (VLM) for
people on antiretroviral therapy (ART), mirroring a model
of care now used in high-income countries. This was
despite no randomized controlled trial having conclusively
shown that VLM improves health outcomes compared to
existing, less expensive alternatives1. WHO’s own
modelling showed that continued scale-up of ART would
deliver 6 times the health gains of adopting VLM at
prevailing costs1.
● Tanzania’s 2013 National Essential Medicines List,
NEMLIT included bevacizumab (Avastin) for cancer
treatment, despite NICE having rejected its use in
England and Wales for lung, ovarian, breast, and
colorectal cancers on cost-effectiveness grounds. The
UK’s total health expenditure per capita was 40 times that
of Tanzania in 2015 (PPP international dollars, WHO
Global Health Expenditure Database).
● Malawi has had an HBP, the Essential Health Package
(EHP), since 2004 and which was revised in 2011.
However, its aspirational nature, exacerbated by the use
of disease burden criteria and arbitrary cost-effectiveness
thresholds in intervention selection, meant that the EHP
was chronically underfunded and essentially unaffordable.
Large coverage gaps for basic low-cost and highly cost-
effective interventions remained, and existing healthcare
inequalities were exacerbated. Conversely, around 20% of
district-level expenditures have been on interventions
outside the EHP1.
https://esa.un.org/unpd/wpp/https://www.cgdev.org/publication/moral-imperative-toward-cost-effectiveness-global-health/https://www.cgdev.org/publication/moral-imperative-toward-cost-effectiveness-global-health/http://www.who.int/whr/2010/en/http://www.who.int/whr/2010/en/http://worldpopulationreview.com/continents/sub-saharan-africa-population/https://www.r4d.org/news/good-ventures-awards-6-4-million-results-development-scale-access-childhood-pneumonia-treatment-tanzania/http://www.globalhitap.net/wp-content/uploads/2016/01/SVR-Tanzania-042015-Formatted-Full.pdfhttp://www.globalhitap.net/wp-content/uploads/2016/01/SVR-Tanzania-042015-Formatted-Full.pdfhttp://apps.who.int/nha/databasehttp://apps.who.int/nha/database
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Page 3 of 31 Grant Proposal Narrative to the Gates Foundation
communicable disease (NCD) burdens alongside skyrocketing demand for all kinds of healthcare and products, at the same time as
donor funds are being withdrawn from all but the poorest of countries. And whilst there is a continuing surge in Africa’s healthcare
spending, from US$28.4bn in 2000 to $117bn in 2012, the effectiveness of this spend is questionable with predominantly private
out-of-pocket (OOP) spending on the rise especially as funders depart. For example, the healthcare commodities market has
undergone particularly dramatic growth, at an estimated 9.8% compound annual growth rate between 2010 and 2020 (5-fold higher
than the US or EU markets) but the bulk of spending comes from private and highly fragmented sources, leading to gross
inequalities and inefficiencies. The availability of private market services and products also drives pressure for coverage and
reimbursement of the same kinds of interventions – many of dubious clinical efficacy – with public monies.7
Many SSA countries are introducing national health insurance schemes for UHC, and looking to a greater role for both public and
private provision of healthcare. This need will accelerate imminently as LMICs transition from external aid. By 2022, 24 countries
are projected to be undergoing simultaneous transitions from external financing, including BMGF focus countries Kenya and
Nigeria, while Ghana and Zambia will have exceeded Gavi eligibility by 20208. Such countries will have to make extremely difficult
decisions on how best to integrate and finance previously donor-funded technologies and health services into their UHC packages,
identifying and balancing tradeoffs among competing health priorities and ensuring that high-quality, affordable access to healthcare
can be provided to the population in a way that is equitable and financially sustainable.
There is an urgent need for ministries of health and finance across SSA to build the required institutional capacity - where
generating and using research evidence to articulate tradeoffs and inform decisions becomes the norm - in order to set cost-
effective priorities in their health planning and health benefit package (HBP) design, and make sustainable investments in their
health systems.
Making every dollar go further
Thanks to the support of the Foundation and others (including the UK Department for International Development [DFID], the
Rockefeller Foundation, and the Wellcome Trust), iDSI has established a track record of helping countries develop sustainable
capacities and mechanisms for effective priority-setting, for example by sharing with policymakers international examples of how HTA
can be used to enhance health system efficiency and equity and providing guidance on how to operationalise HTA institutional
structures witin the given policy context; and providing technical training and coaching to local research teams to generate HTA
evidence which can then inform policy. Our work has paid off – in countries as diverse as China9, India, South Africa10 and Ghana11,
national policymakers are institutionalising HTA12, developing the frameworks to connect analyses to product and service selection,
procurement, price negotiations, and decisions on the uses of health budgets. In China and India alone, where iDSI has respectively
contributed the introduction of HTA into the Essential Medicines List and the first national HTA analysis (intraocular lens for cataract
surgery) to inform listing on the National Health Protection Scheme (“ModiCare”), our work will affect access to services and
commodities for a potential 2.8bn people, over one-third of the world’s population.
As global funders shift strategic focus to LMICs in Africa, the challenge is to replicate and scale the operations and impact of iDSI to
a new and dynamic environment with very different contexts to some of the middle-income Asian countries where iDSI has been
engaging in the past 5 years, and to ensure that LMICs can sustainably transition from aid and develop impactful health systems..
Lands of opportunities
The solution has to be found within Africa and the countries themselves. From iDSI’s early scoping, we know that there is a potential
wealth of talent in health economics and other disciplines necessary for evidence-informed priority-setting, currently spread across
SSA but which is not strongly coordinated13. With support from the Foundation, iDSI proposes to scope out and establish a minimum
of two SSA regional mechanisms that will build a critical mass, in turn plugging into policy and providing responsive, demand-driven
locally relevant technical expertise and data. This will build countries’ predominantly government-owned capacities to translate
knowledge and evidence (including BMGF-global public goods such as those by Disease Control Priorities (DCP) and the Institute of
Health Metrics and Evaluation [IHME]) into real decisions positively impacting people’s lives.
Public health system capacity alone is insufficient to meet growing demand and enable UHC in SSA. The healthare industry, with
growing markets for private healthcare payers and providers across Africa, could be the catalyst to unlock more efficient, equitable,
effective healthcare coverage for millions of citizens. However the realities and pitfalls of unregulated, unpredictable healthcare
markets, as recently highlighted by the Competition Commission in South Africa, require an enabling environment for fairer and
more stable markets which would incentivise genuine good value innovations. iDSI, drawing on HTA and its UK NICE experience of
almost 20 years in engaging with the healthcare industry, is ready to help shape markets and potentially scale up alongside African-
wide health technology and regulatory mechanisms. (see Appendix: Use case for the private sector)
At 5 years old, iDSI is at a critical crossroads. The investment by the Foundation into building lasting national institutions that translate
evidence into policies is beginning to bear fruit. However institutionalisation requires time and sustained investment: in Africa,
regulatory harmonisation has yet to generate a streamlined approval process and the Africa Medicines Agency has only recently been
announced almost 20 years after NEPAD’s establishment in 2001. Without further funding, five years since the first BMGF grant on
the iDSI Reference Case for economic evaluation, there is a risk that fledgling HTA and evidence-informed policy ecosystems will
7 Glassman, Amanda, Ursula Giedion, and Peter C. Smith, eds. What's in, what's out: designing benefits for universal health coverage. Brookings Institution Press, 2017 8 Kallenberg, Judith, Wilson Mok, Robert Newman, Aurélia Nguyen, Theresa Ryckman, Helen Saxenian, and Paul Wilson. "Gavi’s transition policy: moving from development assistance to domestic financing of immunization programs." Health Affairs 35, no. 2 (2016): 250-258. 9 In 2017, HTA-based criteria were introduced into the National Reimbursement Drug List China which resulted in up to 70% price reductions in key high-cost drugs 10 Newly established National Health Insurance fund budgeted in the 2018-2021 Mid term budget review for HTA to analyze the cost-effectiveness of health interventions 11 In May 2018, the Ghanaian government signed the Aide Memoire cementing the role of HTA in optimising drug procurement and supply chains for UHC 12 HTA is the systematic evaluation of health interventions, quantifying and comparing their tradeoffs in terms of costs and health benefits, as to inform resource allocation decisions. HTA is used by agencies to refer both to the policy process and to individual cost-effectiveness analyses. 13 Doherty, Jane E., Thomas Wilkinson, Ijeoma Edoka, and Karen Hofman. "Strengthening expertise for health technology assessment and priority-setting in Africa." Global health action 10, no. 1 (2017): 1370194.
http://www.who.int/health_financing/documents/public-financing-africa/en/https://www.mckinsey.com/~/media/mckinsey/industries/pharmaceuticals%20and%20medical%20products/our%20insights/africa%20a%20continent%20of%20opportunity%20for%20pharma%20and%20patients/pmp%20africa%20a%20continent%20of%20opportunity%20for%20pharma.ashxhttps://www.cgdev.org/publication/initial-estimation-size-health-commodity-markets-low-and-middle-income-countrieshttps://www.cgdev.org/publication/initial-estimation-size-health-commodity-markets-low-and-middle-income-countrieshttp://www.action.org/uploads/documents/Progress_in_Peril_web_updated_103017.pdfhttps://www.clinicalleader.com/doc/coming-rapidly-of-age-health-technology-assessment-in-china-0001https://thewire.in/government/health-technology-assessment-expenditurehttps://dhr.gov.in/sites/default/files/htaincataract_0.pdfhttps://dhr.gov.in/sites/default/files/htaincataract_0.pdfhttp://www.compcom.co.za/healthcare-inquiry/https://www.dropbox.com/s/bn1j5mxo2eidw59/iDSIplus%20Use%20Case%20-%20Private%20Sector%202018-7-6%20RL.pdf?dl=0http://www.nepad.org/content/about-nepad#aboutourworkhttps://www.jstage.jst.go.jp/article/bst/12/2/12_2018.01038/_pdf/-char/enhttp://www.treasury.gov.za/documents/national%20budget/2018/review/FullBR.pdfhttp://www.moh.gov.gh/ministry-of-health-partners-signs-aide-memoire-for-2018-health-summit/
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Page 4 of 31 Grant Proposal Narrative to the Gates Foundation
regress in emerging markets such as South Africa and India – and health resource allocation will fall back to ad hoc, inefficient,
unfair, and driven by perverse incentives. Worse even, HTA agencies may survive not as a technocratic facilitator but as a bureaucratic
hurdle that delays or blocks the uptake of high-value healthcare innovations and discourages private investment.
How iDSIplus will serve the global health community
We believe the only way forward for the global health community is to move beyond a piecemeal, projectised approach to research,
advocacy, and knowledge sharing events, which we believe to be counterproductive to global health goals. Without ongoing
connections to budget decision-makers and payers, the global development community will be trapped in the same vicious circle of
crowding out public spending with external funding, and failing to set up sustainable systems to influence resource allocation
towards best value for money for health. Instead, we propose to use iDSI as a platform to engage with multiple BMGF-funded and
other initiatives, plugging and diffusing global knowledge into practice through policy mechanisms that are country-led and country-
owned. These initiatives include:
• disease- and technology-specific initiatives, e.g. Tufts’ Global Health Cost Effective Analysis (GH-CEA) registry,
HIV/TB/malaria modelling consortia;
• data and indicator generation and evidence synthesis, e.g. Global Health Costing Consortium and Access and Delivery
Partnership [ADP], both of which have memorandums of understanding with iDSI; as well as IHME Global Burden of
Disease, DCP, UCL Dashboard;
• recently launched capacity building work (e.g. Strategic Purchasing African Resource Center [SPARC] and Primary Health
Care Performance Initiative [PHCPI]); and
• networks, e.g. Joint Learning Network for UHC (JLN) with the World Bank (WB)
This will be necessary in order to realise our vision of a truly grand convergence for transitioning LMICs – coordinated, national-level
reforms to build and implement a comprehensive and affordable UHC package including bringing together personal and public
health, NCDs and Millennium Development Goals (MDGs). The latter is of particular importance as PEPFAR, Gavi and other global
funders move on and leave behind little legacy by way of country-owned governance, data or analytical capacity. The gap is huge,
the demand real and articulated by senior local actors (see Appendix: Letters of Support).
How does it all fit together, where is the knowledge, experience and learning centralized? How consistent are the approaches
across entities? And the ultimate test: who will be at the frontline and accountable for the process and decision of whether a
transition country keeps or discards a previously donor-funded activities? There is a core knowledge generation and management
issue, and the need for data and models and reference cases to be consolidated and made public. We are nearing a time – with the
multiple replenishments and aid transition arrangements at stake, where a simple and clear ask of countries will need to be made
with respect to future investments in public health. Many interventions will fall off the list given budget constraints, and the criteria for
deciding what’s in and what’s out should be based at least in part on maximizing health outcomes given the budget available (and
on how big that budget should be). The global health community is not currently organised to provide a joined-up offer. iDSIplus can
help articulate and deliver that joined-up offer.
Through our proposal we set out a sustainable route to scaling up the activities across SSA through regional hubs, working closely
with local institutions and national governments, to sustaining them through leveraging multiple donor funds whilst strengthening
countries’ own capacities to transition from external assistance, and with a view to establishing a business function for iDSIplus to
attract private sector as well as government funding where appropriate.
3. Scope and Approach
Describe the scope and approach of the proposed work. This should be a narrative description of the principal results the
investment would achieve and how those results relate to the problem described above (rather than a list of outcomes and
outputs.) Note: You will provide a list of outcomes and outputs in the Results Framework.
http://www.who.int/health-technology-assessment/MD_HTA_oct2015_final_web2.pdf?ua=1https://www.dropbox.com/sh/gqy6aup7t6xwwvc/AAA2oDv8SnCuQmyqtjBdzt7Ra?dl=0
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Overview
The international Decision Support Initiative (iDSI), through the proposed iDSIplus grant, will serve as a strategic linchpin for the
global health community on resource allocation, maximising impact across disease areas and assuring that:
• Capacities to generate and use evidence are developed among global development partners and national governments
• BMGF investments act as a catalyst, empowering LMICs themselves to invest in key cost-effective global health priorities
• The efforts of development partners such as WHO to improve LMIC policy decisions are more efficient and effective,
drawing on iDSI as a technical resource to work with national priority-setting institutions
• Global funders’ offerings and transition arrangements support the most cost-effective use of funds available
• Research (from R&D to implementation research) attends to cost-effectiveness and affordability considerations using
standard criteria such as the iDSI Reference Case
• All efforts connect with and respond to LMIC governments’ policy processes and local realities, and progress towards
UHC.
Over the next 5 years, iDSIplus will apply the principles, values, methods and expertise of iDSI, as well as from BMGF-funded and
other relevant global knowledge, in LMICs anticipating or entering epidemiological and financing transitions. We envision two broad
types of country: flagship countries, where there is clear unmet demand from policymakers for evidence-informed priority-setting
and local capactities that could be utilised to meet this demand and potentially consolidated into regional hubs to serve demand in
neighbouring countries; and scale-up countries where demand is less clearly articulated and that stand to benefit from our global
and regional hub activities,
In the 5 flagship countries, Kenya, South Africa, Ghana, China, and India, our engagement will serve not only as an end but also
as a means to create global public goods, including data, methods and tools that will be diffused to our scale-up countries across
SSA. We shall build country-owned sustainable institutions and governance mechanisms, with a view to testing our approach to
scale and sustainability through networks and iDSI regional hubs in Eastern and Southern Africa, where we shall convene,
consolidate and build on local and regional capacity. This will enable iDSI to provide 'boots on the ground' presence to respond to
domestic demand, as well as South-South and government-to-government collaboration serving other Africa Team focus countries.
The power of iDSI is in its ability to bring people together, mobilising global and national expertise and building lasting relationships
in a country-led priority-setting process with direct links into national governments and payer organisations. We provide demand-
driven practical support that is sensitive to local contexts, plugged into local policy and politics, and responsive to a country’s
changing needs as it makes progress. This will go far beyond a “fly-in/fly-out” approach that characterises traditional consultancies.
As part of scaling up, countries that may be “less ready” for HTA will require more intense engagement on the ground, in order to
capitalize on windows of opportunity to stimulate demand with key influencers and to ensure that substantive relationships, mutual
trust and local capacity can be built. There is no one-size-fits-all solution, and iDSI will sequence and combine a variety of approaches
as required (Table 1).
Our approach to country practical support14 will involve:
• Dialogues with country stakeholders to diagnose the problem and need,
and help them articulate their demand through targeted advocacy
efforts
• Mobilising in-country government and other partners, by forming
partnerships with and working through trusted local institutions who
understand the context and can bring together relevant policymakers
and researchers to work jointly on HTA-related activities, and through
bidirectional staff placements (iDSI staff in country; and LMIC staff
among iDSI core partners)
• Developing the technical, organizational, convening, and fundraising
capabilities of those local partners, such that as they can sustainably
serve domestic demand alongside regional hub functions
• Regionalising resources where economies of scale and scope can be
built (e.g. evidence generation and synthesis) whilst maintaining our
bespoke, hands-on country-by-country approach to national policy
decisions and governance mechanisms.
14 Examples of past iDSI experience can be found in Tantivess S, Chalkidou K, Tritasavit N and Teerawattananon Y. Health Technology Assessment capacity development in low- and middle-income countries: Experiences from For he international units of HITAP and NICE [version 1; referees: 2 approved]. F1000Research 2017, 6:2119
(doi: 10.12688/f1000research.13180.1)
What are the core principles underpinning a strong
evidence-informed priority-setting mechanism?
Independence. There should be strong and enforced
conflict of interest policies.
Transparency. Analyses, decisions, decision criteria and
rationale for individual decisions should be made public
and accessible.
Inclusiveness. There should be wide and genuine
consultation with stakeholders, and a willingness to
change decision in light of new evidence
Scientific basis. There should be strong, scientific and
economic methods and reliance on critically appraised
evidence and information
Timeliness. Decisions should be produced in reasonable
timeframe; minimise delays in publishing decisions
Consistency. Same technical and process rules should
be applied to all cases
Regular review. Decisions and of methods should be
regularly reviewed.
http://dx.doi.org/10.12688/f1000research.13180.1
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Page 6 of 31 Grant Proposal Narrative to the Gates Foundation
Table 1. iDSI’s flexible resourcing model for a range of country engagement modalities.
Our knowledge products in the form of global public goods drawing on a range of disciplines and grounded in the need for research
to inform priority-setting decisions in LMICs, make our practical support more robust and country-relevant. We shall develop
innovative ways to tailor and apply our flagship knowledge products such as the iDSI Reference Case and the What’s In, What’s
Out guide to HBP design in SSA countries, contributing to and synergising with the WHO’s global guidance efforts where relevant.
We shall build on and utilise global knowledge platforms, including our electronic platforms such as Guide to Economic Analysis and
Research (GEAR) and iDSI Knowledge Gateway with F1000, networks such as African Health Economics and Policy Association
(AfHEA) and HTAsiaLink, and global policy forums such as the Prince Mahidol Award Conference (whose themes for the next 5
years will focus on UHC), with an emphasis on cross-country and cross-regional capacity building and knowledge diffusion.
Exploring such themes as routinely collected data, real world evidence, and Big Data analytics will inform future iDSI country
engagements with the potential to enable African nations to leapfrog existing HTA systems in their trajectories of development.
Reaching scale
Seeded in all country engagement will be the South-South partnership capabilities approach, with a view to creating a “NICE
International” or “HITAP International Unit” in every major flagship country partner. We see the seedlings of this in:
• China, where iDSI core partner CNHDRC have established an HTA network of 33 provincial authorities, and are firming their
position as a development partner for Africa in health priority-setting, as an element of the Belt and Road initiative;
• India, with its hub-and-spokes model with HTAIn at the Central level, and core teams established in technical or academic
institutes in 7 States across the country15, some which are providing technical assistance to State health insurers; and
South Africa, where through earlier iDSI work Tanzania and Zambia have both embedded HTA and economics in their budding
priority setting processes. The Regional hubs section outlines our vision for a Southern Africa and an Eastern African iDSI hub. These
hubs would continue to support these initiatives in their regions.Strategic collaboration with global and regional partners will be critical
to enhancing our scale of influence and impact, geographic and technical scope, and crowding in funding sources beyond BMGF. An
important new partnership will be with the Norwegian Institute of Public Health (NIPH). As the Norwegian government’s agency
conducting systematic reviews and HTA for the Norwegian health system, NIPH will significantly strengthen iDSI’s ability to make a
Typically lower resource requirements Less embedded
Typically higher resource requirements More embedded
Country visits (e.g. workshops, high-level
policy dialogues)
Kenya: Training workshop on
HTA for HBP Advisory Committee
Ghana: Convening iDSI/HTAi and MOH joint event ‘Setting
Priorities Fairly’ for awareness raising among broad
stakeholders
Series of country visits (e.g. targeted
workshops on specific projects)
India: HTA capacity-building workshops over 9 months for State officers, connected to local HTA
decisions
Regional or country hub
Thailand: HITAP providing practical support to SEARO
and WPRO countries
Kenya: KEMRI-WT with strong links to government
and policymakers, and nascent engagement with
Uganda
Embedded country-based consultant
India: Full-time Delhi-based consultant providing rapid
response to DHR and MOHFW, instrumental to the
establishment of HTAIn
Core partnership directly with MOH (with commitment of
MOH resource)
China: Core partner CNHDRC is the
official thinktank of the National Health Commission, potential
provider of South-South expertise under Belt and Road Initiative
Remote coaching on specific projects with
regular virtual meetings, complemented with
country visits
Tanzania: Providing technical input into
streamlining of National Essential Medicines List
Face-to-face coaching on specific
projects
Indonesia, Vietnam: Intensive support by
HITAP to local research teams on HTA studies
and HBP review
Institutional twinning with country-based
partner
Vietnam: OUCRU as local delivery partner for quality standards with a strong hospital network
and MOH links
iDSI full-time staff based over 50% of their
time in-country
South Africa: Placement of iDSI Secretariat senior
adviser to assist in business plan development for NDoH
HTA Unit
iDSI country office
Potential option for future iDSIplus scale-up strategy, subject to funding
Hosting study visits including direct
engagement with senior policymakers in host nations (i.e. Thailand,
China, UK)
China: Annual People-to-People dialogue at health minister level through UK
Foreign and Commonwealth Office, and visits to learn
about PHC and integrated care in the NHS, NICE, etc.
Vietnam: Visits to Thailand’s HITAP and NHSO to learn about evidence-informed
strategic purchasing
Hosting placements / internships at iDSI partner institutions
Indonesia, Vietnam,
Philippines, South Africa: Technical officers from
health ministries and HTA agencies enrolled at Mahidol University
Masters/PhD programme and some as interns at
HITAP
Partnership with organisations that have country offices and in-
country networks
Partnership with CHAI in Ethiopia, South Africa, Zambia, and potentially beyond; work with ODI
fellows
15 https://dhr.gov.in/sites/default/files/eNewsletter/img/HTAIn/HTAIn10-01-2017.pdf
http://www.idsihealth.org/resource-items/idsi-reference-case-for-economic-evaluation/https://www.cgdev.org/publication/whats-in-whats-out-designing-benefits-universal-health-coveragehttps://www.cgdev.org/publication/whats-in-whats-out-designing-benefits-universal-health-coveragehttp://gear4health.com/http://gear4health.com/http://gear4health.com/https://f1000research.com/gateways/iDSIhttps://dhr.gov.in/sites/default/files/eNewsletter/img/HTAIn/HTAIn10-01-2017.pdf
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Page 7 of 31 Grant Proposal Narrative to the Gates Foundation
meaningful contribution through initiating joint work in Ghana then potentially in other countries, and open the possibility of leveraging
future Norad funding.
At a time when aid initiatives in emerging markets are being scaled down, sharing and diffusing iDSI’s global expertise is a low cost
means of supporting the development of Southern centres of excellence so that countries can lead their transition to smart spending.
Grant objectives
The scope of activities will comprise two core programmatic areas, Country Engagement and Knowledge Products (Figure 1).
The two programmatic areas will be synergistic, such that our country engagement will be informed by existing and new iDSI
knowledge products (e.g. the iDSI Reference Case) and at the same time valuable global public goods may arise from the country
work. The cross-cutting Knowledge Transfer and Exchange (KTE) and Advocacy component will feed into and support both
programmatic areas, enhancing knowledge translation, dissemination, diffusion, as well as targeted demand generation in our
scale-up countries.
All activities will be underpinned by well-established and proven project management processes and a fit-for purpose governance
arrangement.
Figure 1. iDSIplus programmatic areas.
Country Engagement Institutional strengthening: Develop institutional capacities and transparent governance processes, enabling maximum health
gains and transition from aid
Smart purchasing: Empower countries to spend their own budgets smarter and implement more efficient and equitable health
benefits packages and delivery platforms, making Universal Health Coverage and SDGs a reality
Country engagement will be oriented towards achieving two closely interlinked strategic objectives: institutional strengthening to
develop lasting in-country institutional capacity for evidence-informed priority-setting; and implementing cost-effectiveness evidence
for smart purchasing for UHC (e.g. evidence-informed health benefits package planning and purchasing). iDSI regional hubs will
enable impact at scale and ensure sustainability beyond donor funding.
Country selection
iDSI’s country engagement plans are illustrated in Figure 2 (SSA) and Figure 3 (Asia). Flagship countries include a subset of BMGF
Africa Team focus countries or where there is local BMGF Country Office presence. The principal criteria for selecting these
countries were:
• ones in which we have already identified a clear and significant demand from respective national policymakers
• known local technical capacity to deliver evidence-informed priority-setting support and which could be leveraged to
develop iDSI regional hubs with a strong likelihood of success
• the work would continue and deepen existing iDSI engagement, likely to last 3 years or more, and lead to measurable and
significant achievements
• political stability.
http://www.idsihealth.org/resource-items/idsi-reference-case-for-economic-evaluation/
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In SSA, we have well established relationships with national payers and the
government in all three flagship countries, Kenya, Ghana, and South
Africa. We propose to adopt an opportunistic approach to specific activities
according to stages of progress towards UHC, shifting political priorities and
locally established longer term commitments. These include current urgent
government requests to expand quality healthcare coverage through whilst
assuring financial sustainability of national health insurance (NHI) schemes.
This engagement will aim to evolve the countries’ respective HTA systems
from early Emergent (where HTA may be conducted ad hoc with limited
links to policy) to a Developed stage, where HTA would routinely inform
policy including in HBP selection and reimbursement, and strategic
purchasing and delivery of services ( Figure 4). Our engagement in all three countries will aim to build the foundations for regional hubs with sustainable
in-country capacity for South-South collaboration.
Democratic Republic of Congo
Kenya East African regional hub at KEMRI-WT (Wellcome core funding) Leveraging DFID funds on GFATM/Unitaid HIV collaboration
Ethiopia
South Africa Potential Southern African regional hub to be scoped out and established Leveraging Wellcome grant on iDSI sister project South African Values and Ethics-UHC Leverage Sida, DFID and other funding via CHAI
Zambia Current iDSI partner country, potential to scale up HBP support via CHAI Potential Southern African regional hub to be scoped out and established Potential: Leverage Gavi funds (proposal under consideration) to support NITAG submission process
Tanzania Current iDSI partner country, potential to scale up HBP/HTA support via KEMRI-WT, HE2RO and KwaZulu-Natal
Uganda Nascent KEMRI-WT unit
Burkina Faso
Cote D’Ivoire
Liberia
Ghana Leverage NIPH expertise on HTA capacity building and potential future Norad funds Potential: West African regional hub to be scoped out, subject to additional funding Potential: Leverage future Japanese government funding via ongoing iDSI global collaboration with UNDP ADP
Malawi
Nigeria
Zimbabwe
Figure 2. Planned iDSIplus engagement in SSA.
How does HTA support strategic purchasing?
By definition, purchasing can only be strategic where there is
evidence, and a rational process to evaluate that evidence,
informing what should be purchased for the given population
and at what price.
Clearly HTA can be that process (or at least part of it), as it is
the case for instance in UK, Thailand and many countries with
mature and well-integrated systems where HTA directly
influences pharmaceutical pricing and price negotiations.
The use of clinical guidelines and quality standards developed
using HTA principles and processes to generate results-based
financing indicators (e.g. Quality Outcomes Framework for
PHC, in the UK and in Thailand) is another example.
“HTA is not about devices or medicines only. It is a scientific
method for Strategic Purchasing.” Dr Lydia Dsane-Selby,
Deputy CEO of NHIA Ghana, at the iDSI/HTAi Setting Priorities
Fairly event (September 2018)
(potential)
http://www.who.int/health_financing/events/D1_S1_Gad_Imperial_College.pdfhttp://www.who.int/health_financing/events/D1_S1_Gad_Imperial_College.pdfhttps://journals.plos.org/plosone/article?id=10.1371/journal.pone.0195179https://www.cgdev.org/blog/more-health-money-through-better-purchasing-decisions-case-ghana
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Page 9 of 31 Grant Proposal Narrative to the Gates Foundation
Figure 4. Indicative iDSI activities change as partners countries' HTA institutional capacity evolves.
In Asia, we shall continue our flagship engagements in India and China, drawing on existing funding from BMGF Country Offices,
and potentially the UK Cross-Government Prosperity Fund in the case of China. Both are strongly committed to using HTA to inform
the direction of UHC, with substantial domestic investment into institutional capacity, and are well on the way to reach a stage of
Laos
Indonesia Scale up HTA policy implementation and MDG/UHC convergence using Gavi and UNDP/ADP funds (proposals under consideration)
Myanmar
Cambodia
Philippines Current iDSI partner country, scale up HTA policy implementation under UHC Law Leverage UNICEF funds to support HTA in RMNCH
China ‘China in Africa’ hub in CNHDRC under Belt and Road Initiative Leveraging UK FCO funds and matched investments from Chinese government
India Potential to leverage Gavi funds (proposal under consideration) to support NITAG submission process
Thailand South East Asia regional hub Consortium including NHF, HITAP, and National University of Singapore Leveraging Thai Research Fund
Figure 3. Planned iDSIplus engagement in Asia.
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Page 10 of 31 Grant Proposal Narrative to the Gates Foundation
development in which they are self-sustaining in the main capacities required and our focus can be on the remaining weaker areas
and supporting scale-up Figure 4). In addition we shall strengthen the South-South collaborative element for both countries to support SSA, building on China’s Belt and Road initiative and BMGF’s China in Africa strategy with a focus on development
assistance in health priority-setting.
Sequencing of practical support activities Figure 5 outlines iDSI's typical strategy (“playbook”) for engaging with countries based on our past experience. Given our demand-driven country support approach, the selection, timing and sequencing of activities will be flexible, may vary from country to country and will depend on the political context at the time. There is no one-size-fits-all solution and it is not intended to be a linear process. And as iDSI's country practical support adapts over time, we should also see a country making progress on the HTA evolution trajectory ( Figure 4).
Figure 5. iDSI strategy for country engagement. .
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When to walk away? Exiting a country engagement
All iDSI engagements have an opportunity cost; that is, financial and human resources committed in one country will not be deployable
elsewhere. To ensure that iDSI is making most cost-effective use of resources and to ensure readiness to respond to new, high value
opportunities, we propose as part of our playbook to build in a review point, ‘When do we walk away?’ at the end of year 2 and every
2 years thereafter, unless unforeseen circumstances (e.g. sudden political change) require a more urgent decision. The review point
will provide an opportunity for iDSI in conjunction with country partners and the Foundation to take stock and make a strategic decision
on next steps.
We anticipate that reasons for exiting will likely include:
• engagement has accomplished its objectives, bringing the project to a natural closure
• engagement has progressed but further engagement is likely to bring diminishing returns, compared to beginning or
intensifying an engagement elsewhere
• lack of progress or momentum
• engagement has progressed but country partners request our withdrawal, including where political changes make further
engagement untenable
At the outset of all country engagements, we shall build the foundationals for sustainable priority-setting capacity, and expect that the
country will eventually ‘transition’ from iDSI support. ‘Exiting’ does not preclude future re-engagement if the need arises despite our
evident that the country remains independently on course. We propose to structure the grant with shorter-term, repeated contracts
with partners to deliver specific activities as necessary, such that if there is a need to exit a country engagement and to pivot elsewhere
we retain the flexibility to reallocate budgets across the programme.
HTA institutional development is a complex intervention and will take years, not months. For example, our first engagements with
Ghana dated from 2012 (as NICE International). We continued with low-intensity visits and exchanges over the years, but it was not
until 2016-2017 that a window of opportunity to pursue a joint HTA analysis on hypertension drugs. This catalysed a whole sequence
of policy reforms in 2018 cementing the role of HTA into HBP selection, drug supply chain and procurement. With countries like China,
where we have engaged for even longer and forged a long-term partnership, our Chinese partners including iDSI core partner
CNHDRC are now generating significant policy impact as the national governement’s trusted technical experts. CNHDRC have been
shaping major ongoing health reforms including the institutionalisation of HTA and its embedding into the Essential Drugs List and
social health insurance schemes. Within iDSIplus, CNHDRC have great potential to be providers of expertise in their own right under
the Belt and Road Initiative across Asia and SSA.
Phasing of country engagements
In the first 2-4 years of the grant, we propose to focus our primarily on the flagship/regional hub countries, including carrying out the
necessary preliminary scoping of in-country partners and potential structures for regional hubs (see below). We shall also sustain
or, where appropriate, initiate engagement in scale-up countries, including convening policy dialogues to articulate a coordinated
and clear ask for relevant stakeholders. By years 4-5, we will expect our regional hubs to begin to ownership of scale-up country
engagements.
Flagship countries
Table 2 outlines the objectives for our flagship countries, the current context and opportunities in each flagship country, key
stakeholders, as well as potential outcomes that could be scaled up regionally and globally. Indicative activities for achieving those
objectives and timeframes are detailed in the Section 11 (Activities).
Strategic objectives
HTA development (current and projected)
Institutional strengthening
Smart purchasing KTE and advocacy Potential for scale and diffusion
Sub-Saharan Africa
Kenya iDSI regional hub for East Africa Population 48.5m Health spend US$70 per capita (5.2% GDP) Target date for UHC: 2022
2018: Emergent (early) 2023: Emergent (late)
Develop framework for institutionalising HTA in the context of national UHC implementation
Support MOH in rationally designing and reviewing the HBP for UHC Develop institutional capacity of the UHC Unit for healthcare priority-setting through proof-of-concept HTA to inform a current policy decision Collaborating with and leveraging funding from global development partners to improve value for money in HIV management and converging NCD and MDG priority setting processes
Facilitate South-South knowledge sharing on HTA, HBP and UHC through peer-to-peer senior policy dialogues with Thailand at the request of the Kenyan MoH
Develop KEMRI-WT’s capacity as regional hub, and also priority-setting capacity of Uganda as its first scale-up country
Establish and strengthen African HTA networks and communities of practice through HTAsiaLink connection Generation of knowledge products relevant to GFF, other development partners and SSA countries (especially methods and dat. Proof-of-concept for operationalising GFATM’s commitment to value for money, and for working
https://f1000research.com/slides/7-979
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with global funders including GFF
South Africa Potential iDSI regional hub for Southern Africa Population 52.3m Health spend US$689 per capita (9.2% GDP) Target date for UHC: 2025
2018: Emergent (early) 2023: Emergent (late) to Developed
Scope out institutional options for a Southern Africa regional hub. Continue to support the development of a sustainable ecosystem for evidence-informed priority-setting for converging National Health Insurance (NHI) and vertical programmes under UHC.
Convene key players in government, academia and other relevant sectors in policy dialogue, to articulate roadmap for operationalizing HTA in NHI decision-making. Convene stakeholders to plan the development of a regional hub.
Strong technical and research capacity and policy influence; ideal spearhead for HTA regionalisation, research funding generation, and capacity strengthening NHI will be one of Africa’s largest health insurance experiments with lessons for federal states Kenya and Nigeria, and how HTA could add value to private sector Generation of knowledge products relevant to GFF, other development partners and SSA countries.
Ghana Potential iDSI regional hub for West Africa Population 25.4m Health spend US$75 per capita (4.7% GDP) 36% NHI coverage achieved in 2013
2018: Emergent (early) 2023: Emergent (late)
Develop framework for institutionalising HTA, building on existing partnership with MoH, academia and National Health Insurance Authority
Advise the National Pricing Committee (NPC) on pricing, procurement, and reimbursement Strengthen provider-payment mechanisms to increase uptake of good value innovations and improve quality of services
Leverage Japanese government (UNDP/ADP), Norad (through NIPH partnership) and other funding sources, including research funding focused on capacity development Future regional hub as gateway to Gates Africa Team focus countries including Nigeria, Liberia, and Sierra Leone
Asia
India Population 1.32bn US$63 per capita health spend (3.9% GDP) Target date for UHC: 2030
2018: Emergent 2023: Developed
Strengthen existing mechanisms for embedding HTA into National Health Protection Scheme, building on existing partnerships with the Ministry of Health and Family Welfare (MoHFW), National Health Agency, State governments, and academic institutions
Strengthen institutional capacity of HTA Secretariat and Technical Appraisal Committee to commission, quality assure, and diffuse HTA evidence to inform the EDL, pricing and strategic purchasing, and deployment of health services Build State level capacity with robust mechanisms for uptake of HTA evidence to support State-level priority-setting towards UHC Gavi-funded activity: Develop NITAG capacity to use cost-effectiveness and other evidence to inform vaccine selection
Facilitate South-South knowledge exchange and joint initiatives between Indian partners and their international counterparts on the use of HTA for defining HBPs
Large population size
Knowledge diffusion between Central-State and State-State levels
HTAIn experience transferrable to SSA countries
Hub-and-spoke approach adopted by India relevant to large federal systems such as Kenya, South Africa, Nigeria, South Africa
China Population 1.34bn Health spend US$426 per capita (5.3% GDP) 95% NHI coverage
2018: Emergent 2023: Developed
Strengthening mechanisms for embedding HTA into the Essential Drugs List, national vaccination programme, and new unified insurance bureau, and building capacity of HTA Centers at Province level
Strengthen policy mechanisms and HTA methods for comprehensively evaluating clinical use of drugs at the national level, from procurement through pricing and reimbursement
Facilitate South-South institutional knowledge exchange with African counterparts in health priority-setting under the Belt and Road Initiative
Large population size China in Africa with technical assistance angle to be a major policy priority for upcoming China international development agency Leverage ongoing bilateral funding support from UK FCO
Table 2. Strategic objectives for iDSIplus flagship country engagements.
Scale-up countries
Scale-up countries are indicative of our diffusion and scale up plans. They involve countries which stand to benefit from regional
hub activities, typically where policymaker demand may not yet be clearly articulated, and the HTA ecosystem is likely to be at an
Embryonic or early Emergent stage ( Figure 4). The engagement will be phased across the grant, initially led by the iDSI Secretariat or co-led with the regional hub, with an expectation that iDSI regional hubs will lead as the grant progresses. The nature of
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Page 13 of 31 Grant Proposal Narrative to the Gates Foundation
engagement will at the beginning likely be exploratory (e.g. scoping, demand generation), or otherwise low in intensity. This may
include discrete activities in such countries where iDSI is currently engaged, or where iDSI may play a supportive role to other
development partners oftentimes also supported by the Foundation (e.g. Ethiopia, where University of Bergen is currently
intensively engaging with Norad and BMGF funding support, alongside CHAI, IHME and others).
In the initial phase of the grant, we shall scale up existing engagement in Zambia and Tanzania where iDSI has to date provided
light touch support on EML and HBP design for UHC, drawing on new partnerships with CHAI and other major players in Southern
and Eastern Africa, and additional funding sources (e.g. Gavi). Through our iDSI East African hub, we shall explore engagement in
Uganda where KEMRI-WT has a nascent unit with links to Makerere University.
Through our South-East Asian regional hub, a consortium of the National Health Foundation (NHF), Thailand, HITAP, and the
National University of Singapore (NUS), we shall also continue iDSI engagement in the Philippines, scaling up policy
implementation of HTA under the recently passed UHC Law. This will leverage our recently awarded UNICEF grant, with potential
synergies to Gates-funded strategic purchasing initiative ThinkWell, and potential global public goods such as HTA methods on
NCDs which will be increasingly relevant to SSA.
In addition, using entirely non-BMGF funding, we shall continued providing technical expertise to local teams on HTA policy
implementation and MDG/UHC convergence in Indonesia, supported through iDSI’s Gavi funding proposal and the Japanese
government-funded Access & Delivery Partnership led by UNDP (UNDP ADP). UNDP ADP focus countries include Ghana,
Tanzania, Zambia, Ethiopia and India, and have indicated iDSI as their preferred partner of HTA technical assistance; this is an
important potential source of funding for iDSI.
Regional hubs
Central to our responsive engagement approach is having trusted implementing partners sharing iDSI’s values and who are able to
provide efficient local (in-country and regional) presence and influence key stakeholders. iDSI has tried a range of types of
collaboration, including working with:
• non-governmental centres of excellence in-country that attract national and international funding, e.g. the Oxford University
Clinical Research Unit (OUCRU) in Vietnam for infectious diseases work
• networks or consortia of academic centres within a country, e.g. States of India for HTA work, with the Postgraduate
Institute of Medical Education and Research (PGIMER) Chandigarh playing an important coordinating function across the
HTA network in India.
• regional hubs illustrating real-world examples of HTA influencing policy, and providing capacity building support to the
wider region whilst serving domestic policy needs, e.g. the role played by HITAP in Thailand and across SE Asia.
In order to scale up their impact and build sustaining capacity to respond to the growing demand for practical support in a greater
number of African countries, iDSI regional hubs will over time serve the following functions:
• Lead and deliver context-specific, responsive practical support to governments and other partner institutions within
the region, and demonstrate policy and ultimately population health impact through implementing evidence-informed
priority-setting
• Diffuse knowledge and scale up impact, by plugging into WHO country and regional offices; regional policy and
economic unions – Southern African Development Community (SADC), East African Community (EAC), and Economic
Community of West African States (ECOWAS); pan-African networks (such as Collaborative Africa Budget Reform
Initiative, AfHEA, AFREHealth); and global networks (such as HTAi, HTAsiaLink and the JLN/WB).
• Convene regional networks and collaborations, with a commitment to form in-country and regional partnerships, and
identify potential new client countries
• Build and strengthen institutional, technical, and informational capacities, in order to attain a critical mass of priority-
setting expertise and allow evidence-informed priority-setting to be self-sustaining
• Secure and leverage additional funding sources to ensure long-term sustainability, for instance through bids to HIC
global research funders that will buy in staff capacity whilst addressing policy-relevant research priorities
Ideal regional hub institutions will have the following key characteristics:
1. An ability and willingness to mobilise and coordinate multidisciplinary capabilities, as required to fulfill demand, and to bring
about a critical mass of expertise. This will be done through strengthening own capacities and through partnerships with
other institutions within the country and beyond. This will require suitable leadership and management capacities as well
as existing health economics and other technical capacities.
2. Being ‘plugged into’ policy, with a clear commitment to supporting policy as a priority over academic research. Having
strong institutional links to government or other decision-making bodies would be advantageous, and crucially having
access to policymakers and the ability (and legitimacy) to influence them
3. Ability to scale up and down operations as required in response to changing demands. This means being able to generate
absorb funding and to build, grow and sustain health economics capacity in-house and also tap into a local and regional
talent pool.
Given that political contexts, the level and interconnectedness of capacity, and institutional relationships will vary from country to
country, we anticipate that regional ‘hubs-and-spokes' may take different forms. In one country, an individual centre of excellence
(whether academic, governmental, or NGO) may play a leading technical role, whereas in another country a regional hub may have
a much more prominent coordination role and working with a consortium of partners with a range of capabilities.
Geographic scope of regional hubs
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To date, iDSI has worked in three countries in Southern Africa: South Africa, Zambia and Tanzania, and developed regional networks
and partnerships. Building on this early work, we shall now scope out options for a Southern African hub, potentially in South Africa
or Zambia, to deliver more intense engagement within Southern Africa. We will also establish a new hub in Kenya, serving East
Africa. The regional hubs for Southern Africa and East Africa will be scoped out from the outset, providing practical support to countries
in the regions during the end, and be self-sustaining by the end of the grant. A potential West African hub will be scoped out towards
the end of the grant and subject to additional funding being sourced.
East Africa
• Regional hub base: Kenya Medical Research Institute Wellcome Trust Research Programe (KEMRI-WT), Kenya
• Potential geographic scope: selected EAC member states and current KEMRI-WT/Wellcome partners - Kenya, Rwanda,
Tanzania, Uganda; also Ethiopia, Democratic Republic of Congo
KEMRI-WT, a centre of excellence in infectious diseases, evidence-based medicine and health systems and policy research with
core funding from the Wellcome Trust, will be a new core partner within iDSIplus. KEMRI-WT have a proven track record of being
able to scale up through their academic research, and more importantly having already established country offices in Uganda and
Tanzania. As part of the MORU Tropical Health Network of Wellcome-funded, Oxford-affiliated clinical research units, KEMRI-WT
has a strong local capacity-building focus (including an in-house research capacity builiding programme), an active research
portfolio and network (including with the London School of Hygiene and Tropical Medicine and its HIV Modelling Consortium – with
whom iDSI is also collaborating), and provides opportunities to leverage Wellcome as well as other philanthropic and research
funding sources. Importantly, like its sister units across Asia (including MORU in Thailand, which has close links with HITAP, and
OUCRU in Vietnam) and unlike most traditional academic institutions, KEMRI-WT has strong ties with the MOH and is uniquely
plugged into knowledge and policy translation.
As the regional hub for East Africa, KEMRI-WT will provide responsive, locally-relevant practical support and capacity-building to
Kenya and the broader region. Its unit in Uganda has strong institutional links with the School of Public Health, Makerere
University, with whom it will be well-placed to scope out potential support on institutionalising evidence-informed priority-setting.
iDSI’s new core partner NHF and HITAP There is also potential for wider knowledge diffusion via the MORU Tropical Health
Network, include its units in the Democratic Republic of Congo, Myanmar, and Laos.
Southern Africa
• Regional hub base: South Africa or Zambia, institution(s) to be determined through scoping exercise in year 1 of grant
• Potential geographic scope: selected SADC member states - Lesotho, Malawi, Mozambique, South Africa, Eswatini
(Swaziland), Tanzania, Zambia, Zimbabwe
In years 1-2, we shall scope out the iDSIplus Southern African regional hub, identifying and selecting suitable candidate partner
institutions through a rigorous and competitive process, potentially in South Africa or Zambia. The hub will play a primary role as a
coordinating body, forming a consortium or community of practice that includes academic institutions, NGOs, government and
public entities, together providing the skillsets required to support priority-setting across Southern Africa and not currently provided
by any existing networks. CHAI is likely to be a major partner given their direct institutional links, significant regional presence and
influence in Southern Africa and SSA more broadly, and potential to leverage funding support from Sida, DFID and others.
iDSI began engaging in South Africa with PRICELESS SA, an academic unit with technical expertise in health economics and
policy influence. Over the past 3 years, PRICELESS has made some progress towards the foundations for an iDSI regional hub,
forming links with networks such as CABRI and AfHEA, and begun engaging in Tanzania and Zambia to introduce evidence-
informed principles and methods into EML review and fiscal policy.
In 2017, as NHI reforms in South Africa gained momentum and HTA began to receive high-level policy buy-in, there was an
unprecedented window of opportunity to influence Africa’s biggest health insurance scheme bringing together public and private
sectors. iDSI made a deliberate strategic decision in conjunction with the Foundation to intensify our engagement with the domestic
agenda. This has by all means been a success, where the Treasury in March 2018 has committed a budget line of 370m rand
(US$25.4m) including an as yet unspecified amount dedicated to establishing an HTA unit.
Yet much work remains ahead to help the NDoH to institutionalise HTA and link it systematically to other components of the
fragmented health system of South Africa. If iDSI is also to deepen and scale up nascent engagements with Tanzania, Zambia
and other countries in the SADC region, this will require mobilising and coordinating a range of capabilities beyond that available to
PRICELESS alone. Herein lies an opportunity to use a South Africa-based hub for servicing the demand for evidence-informed
priority-setting throughout Southern Africa. For this we shall need from the outset to create a coalition of likeminded partners across
Southern Africa through whom the country support will be provided.
We are in discussions with other likely key players among academic institutions (e.g. HE2RO at Wits University where PRICELESS
is also based; Health Economics Unit and Division [HEU] at the University of Cape Town; University of KwaZulu-Natal where
HEARD and the AFREhealth network resides with significant SSA reach) and government and statutory agencies (e.g. South
African Medical Research Council [SA MRC], Human Sciences Research Council; the Council of Medical Schemes (CMS); and the
National Health Laboratory Services).
An alternative location for a Southern Africa hub will be scoped out in Zambia, where iDSI has developed a strong relationship with
the University of Zambia and the MOH, and supported them with policy analysis and HTA capacity-building activites.
West Africa
Subject to additional funding
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• Regional hub base: To be determined, but expected to be identified from centres of excellence in Ghana.
• Potential geographic scope: selected ECOWAS member states – Cote d’Ivoire, the Gambia, Liberia, Mali, Niger, Nigeria
(Africa team focus country), Senegal, Sierra Leone
Ghana, currently moving “beyond aid” and committed to HTA as a means of rationalising its UHC offer, has strong research capacity
in public health and health economics, and with iDSI’s contributions in recent years, an academic community that is increasingly ready
to plug into policymaking with policy-relevant research. Building on the momentum of iDSI/HTAi Setting Priorities Fairly event, the
National Medicines Policy and Aide Memoire of the Annual Healthcare Summit, we shall identify potential institutional partners, and
subject to additional funding begin to scope out the hub structure and functions.
We are in discussions with the MOH, NHIA, and WHO Country Office to identify the ideal location for servicing both domestic and
regional needs. A key partner could include the School of Public Health, University of Ghana, which has strong links to MOH and
NHIA, and ability to leverage funding from Norad and other research funders. Alternatively, the MOH may set up a dedicated
pharmacoeconomics or HTA Unit as our counterpart. Further, we are in the process of signing an MOU with NIPH, and have recently
submitted a joint funding proposal (in collaboration with School of Public Health and MOH) to the WHO and Wellcome on strengthening
capacity for evidence-informed priority-setting. We shall also engage with the Institute of Tropical Medicine (ITM) in Antwerp, which
hosts a community of practice ‘Learning for UHC’ and is an avenue into Francophone West Africa. ECOWAS was highlighted as
another potential networking opportunity with Ghana chairing 6 of the 7 subgroups of the region including regulation and antimicrobial
resistance.
Knowledge products Methods, Processes and Tools: Co-create global public goods to support LMICs and funders in standardizing, contextualizing and
applying approaches to improve value-for-money in health
Data, evidence, and analytics: Generate, integrate and deploy policy-relevant data and knowledge to support better decisions at
global and national levels
iDSI has a track record of developing cutting edge, policy-informing global public goods in health economics and other important
disciplines for evidence-informed priority-setting. Our most important knowledge products to date include:
• iDSI Reference Case which has been adopted and contextualized by government institutions in India and China, and can
serve as a blueprint for national references cases in African nations such as Kenya, Ghana, and South Africa
• What’s In, What’s Out guide to HBP design by CGD, co-developed with LMIC stakeholders and which is now being delivered
in different formats such as courses for senior policymakers, e.g. planned for India in Q4 2019 as it rolls out NHPS.
• GEAR, an innovative global knowledge brokering and rapid response ‘matchmaking’ platform on economic evaluation. It
provides a central resource for LMIC HTA researchers, including hosted guidelines and tools from the Global Health Costing
Consortium.
iDSIplus will build on these investments, widening their reach to SSA audiences through coordinated networking and knowledge
translation efforts. We shall also continue to make our knowledge accessible to researchers and policymakers in LMICs, through the
iDSI Knowledge Gateway, an open access platform in collaboration with F1000 (which also hosts Gates Open Research). To broaden
our scale and scope, we shall also commit to leverage the iDSI network to submit joint research funding proposals with LMIC
institutions to deliver specific policy-relevant academic research activities.
Methods, processes, and tools Going forward, led by the NHF, HITAP and NUS consortium and CGD, we propose to develop three major knowledge products:
• Expansion of GEAR with an emphasis on SSA. GEAR currently has over 400 subscribers of which around 10% (over 40)
are researchers from SSA institutions, and there is significantly potential to increase this through concerted advocacy efforts
among African HTA communities. Content-wise, we shall build on GEAR’s innovative ‘mindmap’ concept, identifying and
providing solutions to technical challenges of HTA researchers and users in African settings.
• Free, open-access decision analysis software that will enable researchers in SSA (LICs in particular) to conduct high-
quality health economic evaluations, including probabilistic uncertainty analysis as recommended by iDSI Reference Case
without being hindered by the prohibitive costs of commercial software
• MOOC on HBP design based on What’s In, What’s Out, in collaboration with the Inter-American Development Bank
HTAsiaLink
HITAP and GHD (formerly NICE International) are founding members of HTAsiaLink. Now with over 40 HTA agencies as
institutional members, it has generated evident value in scaling, diffusion, and capacity development for HTA across Asia, and
sustaining a vibrant regional HTA community focused on generating policy-relevant research.
iDSIplus will continue to strengthen the HTAsiaLink platform. We shall leverage it to translate knowledge among health priority-
setting institutions in Asia and Africa, inviting Kenya, South Africa, Ghana and other countries in SSA to participate in the annual
conference and related research activities (e.g. a network wide survey of HTA use in price negotiations and other pricing
interventions; proposal submitted leveraging Singaporean research funding). HTAsiaLink can also offer high-level institutional
support to SSA regional hubs, with a view to creating an “HTAfricaLink” of budding HTA agencies and academic institutions.
WHO – Total Systems Effectiveness framework
HITAP will work with the WHO Initiative for Vaccine Research on further methodological development and knowledge diffusion of the
Total Systems Effectiveness framework for vaccine evaluations, from the perspective of building HTA systems that recognise
https://www.thecollectivity.org/en/projects/61http://www.idsihealth.org/resource-items/idsi-reference-case-for-economic-evaluation/https://www.cgdev.org/sites/default/files/Whats-In-Whats%20Out-uncorrected-advance-version.pdfhttp://gear4health.com/https://f1000research.com/gateways/iDSI/about-this-gateway
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opportunity costs and acknowledge the challenges of incorporating vertical programmes. The exact scope of activities will be
determined through discussion with WHO and the Foundation.
iDSI will make additional contributions to WHO global public goods on request. We anticipate this to be supported by the WHO-based
technical resource to be housed in Geneva funded by BMGF.
Data, evidence, and analytics
A new programmatic area for iDSI, this will seek to bring together global evidence sources such as BMGF-funded data synthesis,
optimisation and visualisation initiatives; and also harness the mass of routinely collected eHealth, mHealth and related data across
LMICs and SSA in particular, including health and billing datasets from national UHC and NHI programmes, as well as dynamic and
geo-accurate data sources such as DHIS.
Two specific knowledge products will include:
• Comprehensive mapping of SSA economic evaluations in collaboration with the Tufts’ GH-CEA database, which will
identify the most prolific and high-quality research institutions and inform our scoping of iDSI SSA regional hubs
• Scoping of “GEAR for Real World Evidence”, which will create a dialogue forum and technical resource on the
appropriate definition, integration, and political economy of ‘real world evidence’ and ‘real world data’ for decision-making
in LMICs, including SSA. This will draw on iDSI core partners’ experience in HICs such as UK and Canada.
Potential future collaborations, subject to additional funding, could include:
• Drawing on our partnership with NIPH, who have experience of developing and implementing DHIS2 and e-registries in
SSA including an active collaboration in Ghana
• Leveraging CGD project networks and working with other BMGF grantees (e.g. Zenesys, IHME in Ethiopia) engaged in
the use or feedback of HMIS2 to decision-makers
• Tapping into the global learning health systems community and top AI experts and informaticians, through Imperial’s
ROAD2H research project with Serbia and China (CNHDRC). With China, one of the objectives will be to set out the
informational requirements for a dynamic, ‘living HTA’ system using national health insurane claims data and thereby
inform the China Reference Case.
KTE and advocacy
KTE and advocacy: Tailor and deliver evidence-informed messages to influence the right audiences to buy into iDSI’s model,
enabling greater health gains and more value for money
The overarching goal here will be to gain decision-maker buy-in for iDSI’s model to deliver greater health gains and more value for
money. We will anchor activities in synergy with our country engagement and knowledge products, including through engaging with
global policy forums such as the Prince Mahidol Award Conference to advance countries’ commitment to UHC, around five
advocacy objectives:
1. Communicating impact through the dissemination of readily-accessible research and evidence of the impact and cost-
effectiveness of iDSI interventions, drawing from iDSI’s Monitoring, Evaluation and Learning (MEL) component.
2. Positioning iDSI and evidence-informed priority-setting as means to achieve UHC and the SDGs through articulating and
promoting a vision for iDSI-tested and supported approaches that can be widely-owned at the funder and political level
3. Building awareness of the roles of iDSI and evidence-informed priority-setting in achieving efficiency and effectiveness,
particularly on value for money and the efficiency of iDSI-supported health interventions
4. Generating policy outreach through the promotion and facilitation of policy dialogue and learning with information, briefings
and targeted presentations towards key decision makers.
5. Raise iDSI’s profile with potential funding and delivery partners - promoting iDSI’s work and vision through global and
regional media that is seen by key stakeholder groups to build both credibility and a supportive context.
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Strategic global and regional collaboration Strategic collaboration with global and regional partners will be critical to achieving effective and efficient in-country delivery of practical
support, as well as diffusion and scale across countries including those where we may not be engaging directly. Figure 6 outlines how
potential key partners, in addition to aforementioned in-country partners, could inform and support iDSI’s engagements across the
spectrum. Potential collaborative activities are further detailed in the Critical Relationships section, and will be built into the functions
of iDSI regional hubs.
Figure 6. Entry points in countries through global and regional collaborations.
World Health Organization
The WHO will be one of our most important partners given their role in providing global guidance and setting norms, global and
regional convening power, and ability to identifying areas of need and demand from LMICs for technical assistance in evidence-
informed priority-setting for UHC. To date, iDSI has responded to WHO requests for technical assistance to countries looking to
implement the Health Interventions and Technology Assessment resolutions particularly in the South East Asia (SEARO, e.g. India,
Indonesia, Myanmar, Bhutan, Nepal) and West Pacific (WPRO, e.g. Philippines), and coordinated with individual country offices,
e.g. in Ghana and Kenya. Going forward iDSIplus will double down on our excellent working relationships including in the African
(AFRO) region, continuing coordination and joint work in countries including but not limited to Kenya and Philippines (as set out in
the WHO proposal to the Foundation), Ghana, and other countries where WHO have significant local presence – together achieving
WHO’s target of 1bn more people globally to have access to quality UHC by 2020.
As part of their proposal to the Foundation, WHO plan to establish a global network intended to bring together initiatives in the
priority-setting space and we shall be keen to participate as part of that